When a person is clear about the outcome he/she wants to achieve, and this is expressed in a way that can be monitored and recorded, e.g. number of blood glucose monitoring measures in a day, then he/she is more likely to achieve the change. The health care professional needs to help clarify specific but tailored plans according to the acronym SMARTS (Table 5.9). This approach has been cited in the care of diabetic adolescents113. In addition to this, some form of self-monitoring, such as keeping a diary, can also be motivating and will influence the development of an action plan. Motivation lists (Table 5.10) can act as reminders of 'What's in it for me?' and a relapse

Table 5.9. Elements of a SMARTs action plan. Based upon reference 62

Specific The plan needs to be clear, so rather that 'cutting down' the person needs to specify what he/she will do, e.g. walk for half an hour, three times a week; have chips twice a week Measurable It should be possible to monitor or gauge the person's progress. This is easier if the aims are specific, as described above Agreed The plan is negotiated—the person is not forced into the decision by the health care professional

Realistic The plan is achievable—the person is not deciding to run a marathon. Progress needs to be made in small incremental steps in order to build self-efficacy Time-specific There needs to be a clearly defined start point and agreement about how often, how long and when progress will be reviewed Support Support has been found to be an important element in the change process for the health professional, family and friends

Table 5.10. The motivation list of a woman with type 2 diabetes

Reasons why I want to lose weight:

• Feel less self-conscious

• Wear smaller clothes

• Be fitter, i.e. be able to do more strenuous walks and other things—aerobics, etc.

• Getting in the car better, the seat belt fitting better

• Be proud of what I have achieved

• Join in more with the kids

• Doing something for me, not for anyone else

• Get into a leather jacket size 16

• Wear shoes that fit instead of having to buy shoes one or two sizes too big

• Be confident in anything I do without being put down by people around me prevention strategy can identify, ahead of time, actions to employ in a difficult ('high risk') situation. These strategies help transform the individual's intention to change into appropriate action.

However, there are a number of problems that can still arise to frustrate good intentions. Firstly much of an individual's behaviour is habitual or automatic, as described earlier; triggers or cues exist to initiate routine behaviours. In this way, a person does not consciously have to think about what to do next, leaving capacity for other activities. This is known as 'stimulus control', and the theory predicts that unless the person introduces a new set of stimuli to remind him/her of the new change, old cues will trigger previous behaviour. Therefore, it is useful to help people to plan in detail how they would reorganize their lives to incorporate new cues or triggers and ignore old stimuli. For example, someone intending to cut down on sweet biscuits may still need to avoid walking down the supermarket aisle, reaching for the biscuits and putting them in the trolley. He/she may need to reorganize his/her route through the supermarket, either to miss this shelf or to avoid the aisle. For some people, this sort of behavioural intervention will be paramount if they are to succeed; examples include written memos to identify permissible food114 and verbal prompts from staff for self-monitoring charts115. Detailed planning (see Table 5.11 as an example for physical activity) facilities subsequent changes.

Human beings are able to rehearse mentally for events, thus making their subsequent performance a little better. People can be encouraged to anticipate the changes that they might make and imagine the change in order to predict its impact. In this way many problems can be identified in advance and coping strategies developed.

Some of the changes people plan will deny them pleasurable experiences or ways of coping, e.g. smoking or eating. It is helpful to plan an alternative. Stress management or relaxation would need to be employed for those who use cigarettes for calming. A person eating inappropriate food as a reward would need to substitute the food for equally enjoyable rewards.

Table 5.11. Example of the essential questions needed to complete an action plan for physical activity

1. What activity?

2. Where and when?

5. What is the target?

6. How will the person reward him/herself?

7. What will the person do if he/she 'slips'?

8. What are the potential blocks and barriers?

9. How will the person overcome these?

For some there will be final blocks or barriers to be overcome before initiating a behaviour, such as the reactions of other people to blood monitoring at work, the difficulty of eating at regular times when meetings run over, etc. At this point a problem-solving approach is needed. The health care professional may give advice, but the basic principles of counselling emphasize that people do better when they generate their own solutions41. A simple protocol suggests: (a) identify the problem; (b) brainstorm solutions; (c) choose a solution; (d) implement the chosen option; (e) evaluate its success. This sequence can be repeated if necessary, or the individual may decide on a number of options to implement simultaneously.

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